Clinical commentary on acute injuries.
In case of acute injuries, a widely used recommendation is using ice, compression and elevation to manage the injury. However, this recommendation is often built up around expert opinion with a limited evidence of high content to support it. The mission of this clinical commentary is to provide an updated summary of current evidence of acute injury management, and some general thoughts on the use of ice in a clinical practice.
The acute injury
The primary purpose for acute injury management is in the short term to limit the inflammatory process, and in the long term, to get the athlete to return to sport.
When an acute strain or tear of a ligament or a muscle occurs blood and fluid from the ruptured area is released into the tissue. When the pressure in the tissue increase, a chain of chemical inflammation markers on a molecular- and cellular level get activated, and these changes will reveal classical clinical inflammation response as pain, swelling, loss of mobility, redness or heat.
The use of ice/cooling is one of the simplest and oldest preferred treatment approaches to acute injuries and ice/cooling has often been associated with having an anti-inflammatory effect which reduce the swelling and pain. Although ice/cooling is widely accepted, there is a growing skepticism whether ice/cooling has an anti-inflammatory effect, and it’s effect on acute injuries.
RICE, PRICE, PRICEM and POLICE
For many years, the basic principle for manage acute injuries has been the acronym RICE (Rest – Ice, Compression, Elevation). Since then, the acronym has changed to PRICE and PRICEM with emphasize on Protection (prevention against further damage) and mobilization (Movement). During the last couple of years several researchers have questioned the used of PRICE, and in 2012 Bleakley, Glasgow and MacAuley, in an editorial in the British Journal Of Sports Science suggested to updating and changing the acronym PRICE to POLICE – Protection, Optimal loading, Ice, Compression, Elavation.
The acronym POLICE provide a practical guide to manage acute injuries. The change from previously acronyms is the replacement of ‘Rest’ to ‘Optimal Loading’. However, Optimal Loading also is an undefined term, it encourages the clinician to began early loading instead of rest.
For a short period of time, it may be necessary to immobilize the injured to minimize the risk of provoking the tissue further. In this stage, the athlete can use a sling, brace, boot, tape or something similar to protect the injured body part.
For the must acute injuries, a two days protection will be enough to remodeling the necessary pulling strength to resist mild loading. For major ligaments injuries a longer immobilization period up to 10 days with controlling loading can be necessary (3), however, the most injuries need optimal loading as quickly as possible (4).
Optimal loading (OL)
The purpose of introducing Optimal Loading is to alter the focus from keeping an acute injury in rest and to emphasize more movement and loading. Different previously research has shown that early loading can contribute with a beneficial effect on muscle strength, muscle mass, tendon tissue and the neuromuscular system (5,6,7).
However, there is no optimal dose-response for optimal loading, and optimal loading should more be seen as a holistic principle that takes into account the biomechanical stress given in a functional exercise on the injured tissue.
Ice (and other forms of cryotherapy) is one of the most used acute treatment approaches (8). The purpose of icing is to reduce pain and minimize swelling in the injured area so that the initiation of movement can begin as soon as possible after the injury.
One of many things, the analgesic effect is due to the influence of the nerve endings in the skin, whereby cooling will decrease the sensitivity of cutaneous skin receptors. Thereby, the firing capacity and nerve conduction velocity (NCV) inhibition, which results in less muscle tonus and pain experience.
To achieve a clinically relevant cooling, studies has shown, that skin temperature should drop to 13°C to achieve a 10-30% reduction in NCV (9, 10), however, there is no clear evidence about the duration and the temperature of the ice, and therefore it must be up to the clinician and patient to judge when the goal of the used of ice is reached.
A wet towel can be placed between the skin and the ice bag to avoid skin damage from the ice.
Opposite to skin temperature, we know from animals studies in vivo, that cooling of muscle tissue between 5-15°C can reduce damage to cellular metabolism, and thereby limit the tissue damage (11). This could be beneficial in surgery (cardiac surgery, amputation or when transporting an organ) where the supply of ice / cooling can be placed in the intended tissue layer and thereby help to reduce cell death that may occur in conjunction with surgery. However, it is doubtful that this cellular gain from surgery will be able to be transferred to acute injury management, as the cooling effect of the muscle will depend on the temperature degree of the ice, the muscular tissue thickness and the cooling time. According to Bleakley, Glasgow and Webb, 2011 (11) have only one study managed to reduce the muscle to 21°C one centimeter down the tissue. With this in mind, it can be questionable if ice/cooling has any effect on a cellular level as the cooling effect gradually decreases, when the cooling finds it way down in the muscle layer, and practical it will never reach the target 5-15°C.
Compression is often used after an acute injury with the purpose to reduce swelling and edema. The duration and tightening of compression is often built on a personal feeling, but despite lack of consensus, Brukner and Khan recommends to use a light to a moderate pressure between 15-35 mmHg, where compression up to 80 mmHg is not more effective (3).
The rationale behind elevation exists from physiological principles, where the injured area is placed above the level of your heart. This will result in a decrease in hydrostatic pressure, which reduces the amount interstitial fluid. For the upper limb a sling can be used to elevate, and for the lower limb, a pillow or chair can be used to keep the limb up. In practice, elevation can be combined with ice and compression.
When an acute injury occurs, the athlete should be removed from further danger (P). The athlete will be asked to move the injury area within pain limit (OL). Within a few minutes, a decision can be made as to whether an athlete can continue playing, or if the injury should be protected further. In case the injury should be protected, applying I-C-E begins with an ice bag, compression bandage with moderate pressure around the injury, as well as elevate above heart level. 15-20 minutes later the ice bag is removed and the injury evaluated. O-L introduced continuously, and I-C-E can be repeated to control pain and swelling in the first minutes, hours and days.
Should we change RICE to POLICE
With this clinical commentary, I hope to contribute to spreading the POLICE acronym to a health professional, so we move forward from the RICE acronym. POLICE provide an effective control of inflammation on more level. Although Ice/cooling do not have a major effect as previously assumed, ice is still a very harmless way to decrease the pain experience without increased risk for further damage. Ice/cooling would therefore just be either ‘trivial’ or ‘beneficial’ for initiate movement.
As clinicians, it is still my personal opinion that Ice / Cooling is a fundamental principle of acute management (particular the pain management) as a part of the POLICE acronym. Therefore, currently is see no reason to let the ice melt in the treatment bag, however, we should change some of our explanations models for why we used it, to avoid nocebo or wrong beliefs. If no pain is present, ice is not a necessary part of the acute management.
- Scott A, Khan KM, Roberts CR, Cook JL, Duronio V. What do we mean by the term “inflammation”? A contemporary basic science update for sports medicine. Br J Sports Med. juni 2004;38(3):372–80.
- Bleakley CM, Glasgow P, MacAuley DC. PRICE needs updating, should we call the POLICE? Br J Sports Med. 1. marts 2012;46(4):220–1.
- Brukner & Khan’s Clinical Sports Medicine: Injuries (Australia Healthcare Medical Medical) af Peter Brukner (Bog) – køb hos Saxo [Internet]. [henvist 30. juni 2017]. Tilgængelig hos: https://www.saxo.com/dk/brukner-khans-clinical-sports-medicine-injuries_peter-brukner_hardback_9781743761380
- Optimal loading: key variables and mechanisms | British Journal of Sports Medicine [Internet]. [henvist 1. marts 2017]. Tilgængelig hos: http://bjsm.bmj.com/content/early/2015/01/06/bjsports-2014-094443
- Wall BT, Dirks ML, Snijders T, Senden JMG, Dolmans J, van Loon LJC. Substantial skeletal muscle loss occurs during only 5 days of disuse. Acta Physiol Oxf Engl. marts 2014;210(3):600–11.
- Järvinen TA, Järvinen M, Kalimo H. Regeneration of injured skeletal muscle after the injury. Muscles Ligaments Tendons J. oktober 2013;3(4):337–45.
- Provenzano PP, Martinez DA, Grindeland RE, Dwyer KW, Turner J, Vailas AC, m.fl. Hindlimb unloading alters ligament healing. J Appl Physiol Bethesda Md 1985. januar 2003;94(1):314–24.
- Cooke MW, Lamb SE, Marsh J, Dale J. A survey of current consultant practice of treatment of severe ankle sprains in emergency departments in the United Kingdom. Emerg Med J EMJ. november 2003;20(6):505–7.
- ACPSM_Physio_Price_A4.indd – ACPSM_Physio_Price_A4.pdf [Internet]. [henvist 30. juni 2017]. Tilgængelig hos: https://www.physiosinsport.org/media/wysiwyg/ACPSM_Physio_Price_A4.pdf
- The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance | British Journal of Sports Medicine [Internet]. [henvist 30. juni 2017]. Tilgængelig hos: http://bjsm.bmj.com/content/41/6/365
- Cooling an acute muscle injury: can basic scientific theory translate into the clinical setting? | British Journal of Sports Medicine [Internet]. [henvist 1. marts 2017]. Tilgængelig hos: http://bjsm.bmj.com/content/early/2011/06/15/bjsm.2011.086116
Some of my presentation slide from a previously workshop.